Quadriceps tendon vs hamstring autograft in primary ACL reconstruction - a comparative study with minimum two-year follow-up.

Recently there has been growing interest in the quadriceps tendon (QUAD) as a valid option for reconstruction of the anterior cruciate ligament (ACLR). The aims of the study is to compare the outcomes achieved in anatomic ACLR involving QUAD vs. Hamstring (HT) autografts. A total of 52 consecutive patients underwent an ACLR, 25 patients with QUAD graft and 27 with HT graft. The same surgical technique, fixation method and postoperative protocol were used in both groups. The following parameters were evaluated: functional status (Lysholm, Tegner, subjective IKDC scores), joint stability (Lachman and pivot shift tests), surgical reoperation rate, complications, degree of satisfaction and return to previous level of activity. Descriptive statistics were analysed using the Student's t-test. Forty four patients were evaluated (20 QUAD, 24 HT), with a mean follow-up of 27.4 months. Two patients were re-operated in the QUAD group (including one ACL revision), and one patient in the HT group required an ACL revision. There were no significant differences between the two groups in postoperative scores: Lysholm (96.05 vs. 96.05), IKDC (86.2 vs. 91.2) and Tegner (6 vs. 5) scales. The percentage of negative Lachman and pivot shift tests was similar in the two groups (45% vs. 50% and 40% vs. 45.8%, respectively). There were no significant differences between the groups in the degree of satisfaction (95.8% vs. 80%, p = .16) or in the percentage who returned to their previous level of activity (62.5% vs. 45%, p = .17). The use of a QUAD graft in ACL reconstruction leads to similar clinical and functional outcomes to those obtained with HT.

Ultrasound-guided genicular nerves block: an analgesic alternative to local infiltration analgesia for total knee arthroplasty: A noninferiority, matched cohort study.

BACKGROUND: Standard analgesic strategies for total knee arthroplasty employ local infiltration analgesia. Blockade and radiofrequency ablation of the genicular nerves are effective treatments for patients with chronic pain because of knee osteoarthritis. OBJECTIVE: To test the noninferiority of the analgesic effect of genicular nerves block in comparison with local infiltration analgesia after 24 h of total knee arthroplasty. DESIGN: Prospective cohort study. SETTING: Perioperative setting. PATIENTS: Thirty-five patients scheduled for total knee arthroplasty were prospectively included in the study and compared with 35 patients in a retrospective cohort. INTERVENTION: Genicular nerve blocks in the prospective cohort were compared with local infiltration analgesia in the retrospective cohort. MAIN OUTCOME MEASURES: The pain numeric rating scale and the cumulative opioid consumption in oral morphine equivalents during the first 24 h. RESULTS: We conducted propensity score-matched analyses of patients using acute postoperative pain-related risk covariates. After one-to-one propensity score matching, 21 patients were included in the local infiltration analgesia group and 21 in the genicular nerve block group. The median difference in numeric rating score at rest at 24 h was -0.99 [95% confidence interval (CI), -1.99 to 0.5, P = 0.012] on the unmatched cohort and -1.9 (95% CI, -2 to 0, P = 0.002) on the matched cohort (meeting the noninferiority criteria, Δ=1). The median difference in cumulative opioid consumption was 2.5 mg (95% CI, -13.5 to 2.5, P < 0.001) for the unmatched cohort and 4.99 mg (95% CI, -11.5 to 2.5, P < 0.001) on the matched group (meeting the noninferiority criteria, Δ = 21 mg). CONCLUSION: Local infiltration analgesia and genicular nerve block are comparable in terms of analgesic results. Therefore, genicular nerves block is an alternative to local infiltration analgesia in patients undergoing total knee arthroplasty. TRIAL REGISTRATION: Clinicaltrials.gov identifier: NCT04024319.

Safe drilling angles avoid femoral tunnel complications during combined anterolateral ligament and anterior cruciate ligament reconstruction.

PURPOSE: To determine the best angle to drill the femoral tunnels of an anterolateral ligament (ALL) anatomic reconstruction combined with a single-bundle anterior cruciate ligament (ACL) reconstruction to avoid tunnel collisions and cortical disruption. METHODS: Ten cadaveric knees were studied. Single-bundle anatomic ACL femoral tunnels were arthroscopically drilled. The starting point of the ALL femoral tunnel was located posterior and superior to the lateral epicondyle. ALL tunnels were drilled at four different angulations: (1) 0° axial/0° coronal, (2) 0° axial/30° coronal superior, (3) 30° axial anterior/0° coronal, and (4) 30° axial anterior 30° coronal superior. Specimens were scanned by computed tomography to measure the relations of each trajectory with the ACL socket and the nearest cortical bone. RESULTS: None of the four trajectories studied presented risk of collision with the ACL. The tunnel at 30° anterior/30° proximal presented the safest distance to the ACL socket (P = 0.01) [mean distance 18.6 mm (SD ± 6.7)]. However, both tunnels angled at 0° in the axial plane presented a high risk of posterior femoral cortex disruption (P = 0.01), either by close proximity or direct contact in some specimens (mean distance 3.1 mm (SD ± 2.8) at 0° axial/0° coronal and 3.7 mm (SD ± 2.2) at 0° axial/30° coronal). CONCLUSIONS: When performing simultaneous ACL and ALL ligament reconstruction, the ALL femoral tunnel should be drilled with an angle of 30° anterior in the axial plane and 30° proximal in the coronal plane. Tunnels with an angle of 0° in the axial plane showed high risk of contact and disruption of the posterior femoral cortex; thus, these angles should be avoided. The clinical relevance of this work is that an ALL anatomical reconstruction does not represent a risk when performing a simultaneous ACL reconstruction as long as the ALL tunnel is reamed with a proximal and anterior angulation.

Suprascapular nerve palsy after arthroscopic Latarjet procedure: a case report and review of literature.

The Bristow and Latarjet procedures have become popular among orthopaedic surgeons thanks to the development of new instruments that allow the use of arthroscopic techniques to treat cases of glenohumeral instability with bone defects or capsular deficiency. Nonetheless, several complications have been reported after Latarjet procedures, including neurological injuries. This report describes surgical damage to the suprascapular nerve, an unusual complication. Level of evidence Expert opinion, Level V.

MR-arthrography assessment after repair of chronic meniscal tears.

PURPOSE: The aims of this study were to assess the healing rate of repair of chronically torn meniscal tear with MR-arthrography and to evaluate the relationship between the clinical and the radiographic outcomes and the impact of the meniscal section on healing. METHODS: MR-arthrography was performed at a median of 10.5 months (range 6-55) after surgery in 28 patients and healing assessed using Henning's criteria. All lesions were chronic (>3 months). Repairs were carried out at a median 14 months (range 6-80) from initial diagnosis. Eleven patients (39%) had ACL ligament reconstruction as well. All lesions were located in the red or red-white zone. Patients were followed for a median of 18.5 months (range 8-68). Functional outcomes were evaluated using Barrett's healing criteria, Lysholm and Tegner score pre- and postoperatively. RESULTS: Clinical healing of the lesion according to Barrett's criteria was achieved in 24 patients (85.7%). Both Lysholm and Tegner scores improved significantly after the surgery (p < 0.05). According to Henning's criteria, 15 of the menisci healed completely (53.5%), 10 partially (35.7%) and 3 failed (10.8%). There was no significant difference between the healing process in the posterior horn and the body of the meniscus (n.s.). No correlation was found between the healing results and the clinical scores. ACL reconstruction did not influence the healing process (n.s.). Patients waiting more than 1 year from lesion to surgery seem to have a higher rate of failure (p = 0.02). CONCLUSIONS: The results found suggest good short-term clinical and anatomic outcomes post-repair of meniscal lesions, despite their chronic nature. Longer waiting times may have negative effects on the healing process. Partial healing occurred often, but the meniscus was painless and stable. LEVEL OF EVIDENCE: Retrospective case series, Level IV.

Severe and morbid obesity (BMI ≥ 35 kg/m(2)) does not increase surgical time and length of hospital stay in total knee arthroplasty surgery.

PURPOSE: Certain aspects of total knee arthroplasty (TKA) in severely and morbidly obese (SMO) patients (BMI ≥ 35 kg/m(2)) remain controversial. This study aimed to assess the duration of TKA surgery and hospital stay in relation to patients' BMI. METHODS: Three operative times during TKA surgery were recorded: tourniquet time, to determine surgical difficulty, total surgical time, to assess the difficulty of achieving anaesthesia, and time in the surgical area, to assess patient management in the surgical area. Length of hospital stay was also calculated. Data were collected prospectively from consecutive patients and were recorded in a database for retrospective analysis. RESULTS: Data were obtained from 922 consecutive patients undergoing TKA. The non-obese group comprised 418 patients (45.3%), obese group Class I 331 (36%), and the SMO group (Class II-III) 173 (18.7%). Mean tourniquet time was 53 min, mean total surgical time was 84 min, and mean time in the surgical area was 132 min. There were no differences according to BMI group. Median length hospital stay (LHS) was 6 days in all patients regardless of BMI. Factors that significantly prolonged LHS were ASA III-IV and pre-operative haemoglobin between 12 and 13 g/dl. CONCLUSION: Severely and morbidly obese (SMO) patients (BMI ≥ 35 kg/m(2)) undergoing TKA surgery do not require longer operative time or hospital stay than non-obese or obese Class I patients. The fact that surgical time was not significantly different could be due to greater specialisation in the treatment of these patients, which may favour a lower incidence of post-operative complications. LEVEL OF EVIDENCE: Retrospective comparative study, Level IV.

Return to recreational sports activity after anterior cruciate ligament reconstruction: a one- to six-year follow-up study.

INTRODUCTION: The aim of this study was to evaluate mid-term return to recreational sport in general population and identify factors related with sports return. METHODS: Retrospective evaluation of 99 recreational sports players (Tegner score of 6) with ACL arthroscopic reconstructions with hamstring autograft, between 2006-2011. 74 male and 25 female with middle age of 30 years (14-52). We made a questionnaire focused on sports level before injury and after surgery, and different scales: Lysholm, Tegner Activity Level, IKDC and a Likert scale for quantify their motivation for return to sports. RESULTS: With a medium follow-up of 36 months, 90 patients (91.9 %) had returned to recreational sport. 51 (51.52 %) had returned to sports at the same level, and these are those with lower BMI (average 23), higher IKDC and Lysholm scores (p < 0.01) and also they believe that sport is an important activity. Only 9 % of patients left sports. They were principally male athletes (88 %), with higher medium age (32), lesser time between injury and surgery (22 months), higher BMI (26), in comparison with athletes that return to sports. CONCLUSIONS: The results suggest good mid-term return to recreational sports in general population. The following factors had a statistically significant influence on the return to sports activity: type of sport, sex and functional state of the operated knee (IKDC-Lysholm). Psychological and social factors may have a fundamental influence on return to sports activity.

Acute acromioclavicular dislocation: a cheaper, easier and all-arthroscopic system. Is it effective in nowadays economical crisis?

The objective of this manuscript is to show an effective, easier and cheaper way to reduce acute acromioclavicular (AC) dislocation type III and V (Rockwood classification). Numerous procedures have been described for surgical management of acromioclavicular joint disruption. Newest devices involve an arthroscopic technique that allows nonrigid anatomic fixation of the acromioclavicular joint. Arthroscopically assisted treatment of acute AC joint dislocation is advantageous because it provides good clinical results and few complications. It also allows reviewing glenohumeral associated lesions. This surgical technique requires no specific implants to achieve a correct AC reduction. Actually, economical advantages are very important factors to decide the use of determinate surgical techniques.

Health-related quality of life and direct costs in patients with anterior cruciate ligament injury: single-bundle versus double-bundle reconstruction in a low-demand cohort--a randomized trial with 2 years of follow-up.

PURPOSE: To evaluate health-related quality of life (HRQL) in patients undergoing anterior cruciate ligament (ACL) reconstructive surgery by use of 2 procedures and to estimate the direct costs of surgery. METHODS: We performed a 2-year randomized, prospective intervention study of 2 surgical ACL reconstruction techniques (anatomic single bundle [SB] v double bundle [DB]). Fifty-five consecutive outpatients, with a mean age of 30.88 years, were randomized to SB or DB ACL reconstruction. The Medical Outcomes Study 36-item Short Form Health Survey (SF-36) was used to measure HRQL (primary outcome). ACL injuries were assessed by the International Knee Documentation Committee (IKDC) score (secondary outcome). The use of medical resources and their costs were evaluated. RESULTS: We included 52 patients in the final analyses (23 in the SB group and 29 in the DB group). At baseline, there were no significant differences in study variables. At 2 years of follow-up, there were no significant differences in SF-36 and IKDC scores between groups. However, compared with baseline, the SF-36 physical function, physical role, bodily pain, social function, and emotional role scores were significantly better in the SB group (P < .05), whereas only the physical function dimension score was better in the DB group (P = .047). IKDC scores at 2 years improved significantly in the SB group (P < .001) and DB group (P = .004) compared with baseline. There was a significant correlation between the SF-36 physical function, physical role, and bodily pain dimensions and the IKDC score at 2 years (P < .05). The costs were € 3,251 for the SB group and € 4,172 for the DB group. CONCLUSIONS: HRQL and medical outcomes were similar between SB and DB ACL reconstruction techniques, 2 years after surgery. However, the SB technique was more cost-effective.

Is elective surgery during the COVID-19 pandemic safe? A multi-center prospective study in a high incidence area.

OBJECTIVE: The aim of this study was to describe the evolution of patients admitted for elective orthopaedic surgery during the immediate post-COVID-19 peak of the pandemic. METHODS: This is a multi-center, observational study conducted in 8 high complexity hospitals of Catalonia, one of the highest COVID-19 incidence areas in Spain. We included patients ≥18 years of age undergoing elective surgery (total knee or hip arthroplasty, knee or hip revision arthroplasty, shoulder or knee arthroscopy, hand or wrist surgery, forefoot surgery, or hardware removal) after the COVID-19 peak (between May 5th and June 30th, 2020). The main exclusion criterion was a positive result for SARS-CoV-2 PCR within the 7 days before the surgery. The primary outcomes were postoperative complications within 60 days (+/-30) or hospital readmission due to a COVID-19 infection. Following the recommendations of the International Consensus Group (ICM), elective surgeries were re-started when the nationwide lockdown was lifted. Before the surgery, patients were contacted by phone to rule out any exposure to confirmed COVID-19 cases, a reverse transcription-polymerase chain reaction (PCR) assay was performed in all patients 48-72 hours before hospital admission, and they were asked to maintain home confinement until the day of the surgery. RESULTS: 675 patients were included: 189 patients in the arthroplasty group (28%) and 486 in the ambulatory surgery group (72%). Mean [SD] age was 57.6 [15.3] years. The mean Charlson Comorbidity Index score was 2.21 (SD = 2.01, Min = 0, Max = 13). A total of 84 patients (12.75%) obtained an American Society of Anesthesiologists (ASA) score ≥ 3, showing no association between the ASA score and the risk of developing COVID-19 symptoms at follow-up (χ 2 (4) = 0.77, P = 0.94). The mean occupation rate of hospital beds for COVID-19 patients was 13% and the mean occupation rate of critical care beds for COVID-19 patients was 27% at the time of re-introducing elective surgeries. These were important rates to consider to decide when to reintroduce elective surgeries after lockdown. Surgical time, time of ischemia and intra-operative bleeding were not related with a higher risk of developing COVID-19 post-operatively (χ 2 (1) = 0.00, P = 0.98); (χ 2 (2) = 2.05, P = 0.36); (χ 2 (2) = 0.37, P = 0.83). Only 2 patients (0.3 %) presented with a suspected COVID-19 infection at follow-up. None of them presented with pneumonia or required confirmation by a reverse transcription PCR assay. Hospital re-admission was not needed for these patients. CONCLUSION: The risk of developing COVID-19 during the immediate post-COVID-19 peak in a region with a high incidence of COVID-19 has not been proved. These data suggest that elective orthopaedic surgeries can be resumed when assertive and strict protocols are followed.

Factors influencing health-related quality of life after TKA in patients who are obese.

BACKGROUND: Although the health-related quality of life (HRQL) for patients who are obese seems to improve after TKA, the magnitude of improvement and the associated factors remain controversial. We previously found body mass index was not associated with changes in HRQL after TKA. QUESTIONS/PURPOSES: The purposes of this secondary analysis were to determine which patient characteristics and surgical factors were associated with worse health status after TKA in patients who are severe or morbidly obese. METHODS: We assessed 60 patients (53 females; mean age, 70 years) 12 months after surgery. The mean number of comorbidities was 2.5. Mean lower limb anthropometric index scores were: suprapatellar, 1.6; infrapatellar, 2; and suprapatellar/infrapatellar, 1.2. Intraoperative difficulty (IOD) was Grade 0, 40%; Grade 1, 48%; and Grade 2, 12%. Ten patients (17%) had complications. We measured HRQL using the disease-specific WOMAC questionnaire. Patient characteristics (sociodemographic variables, BMI, comorbidity, lower limb anthropometry) and surgical factors (IOD, complications, postoperative medical data) were collected. Associations between WOMAC dimension scores at 12 months and patient characteristics and surgical factors were analyzed using linear regression models. RESULTS: Factors associated with worse WOMAC dimension scores in patients who were obese included the number of comorbidities, an infrapatellar index percentile less than 75, IOD Grade 2, and the number of complications after discharge. CONCLUSIONS: For patients with knee osteoarthritis who were severe or morbidly obese, various lower limb anthropometric features, degree of IOD, and postoperative complications negatively influenced postoperative WOMAC scores. LEVEL OF EVIDENCE: Level II Prognostic Study. See Guidelines for a complete description of levels of evidence.

Experiences during Switching from Two-Stage to One-Stage Revision Arthroplasty for Chronic Total Knee Arthroplasty Infection.

The objective of this study was to evaluate our preliminary results after changing our surgical strategy from 2-stage revision arthroplasty to 1-stage revision arthroplasty for patients with chronic knee periprosthetic joint infection. We conducted a prospective study of knee arthroplasty patients that had been diagnosed with chronic infection and treated using a 1-stage revision regardless of the traditional criteria applied for indication thereof. We evaluated two main variables: infection control and economic costs. The definitive diagnosis of infection of the revision was determined by using the criteria proposed by the Musculoskeletal Infection Society. The costs were calculated as average costs in USD, as described by Srivastava (2019), for 1-stage or 2-stage revisions. Eighteen patients were included in the study, and infection was controlled in 17 patients. The total economic savings for our hospital from these 18 patients amounted to USD 291,152. This clinical success has led to major changes in how our hospital approaches the treatment of chronically infected knee replacements, in addition to substantial economic advantages for the hospital.

Double-bundle versus single-bundle ACL reconstruction using the horizontal femoral position: a prospective, randomized study.

The aim of this study was to evaluate whether anterior cruciate ligament (ACL) reconstruction using the double bundle technique (DB) improves stability in the knee compared with the single bundle technique (SB) with the femoral tunnel in a more horizontal position (2 or 10 o'clock). We conducted a randomized, prospective study. Forty patients were randomized to the DB group (20 patients) and the SB group (20 patients). Four-stranded semitendinosus and gracilis autologous grafts were used in the SB group and in the DB group the conventional four tunnel technique was carried out using the same tendons. The IKDC complete form was used for the preoperative evaluation, and in the follow-up the IKDC subjective knee evaluation form, IKDC current health assessment form and IKDC knee examination form were used. Anteroposterior (AP) laxity was evaluated by standardised and forced radiology in all patients. No significant preoperative between-group differences were found. During the follow-up, no differences were found between groups, except for significant between-group differences (P < 0.05) between the preoperative and postoperative evaluations. The IKDC index also showed significant differences in the 2-year follow-up. Median scores increased from 48 (range 41-54) to 81 (range 75-87) (P = 0.01) in the SB group and from 52 (range 46-58) to 80 (range 72-88) (P = 0.02) in the DB group. There were no significant differences between the groups in terms of functional scores. In conclusion, the 2 and 10 o'clock placements showed no significant differences between SB and DB techniques in the pivot-shift test, manual and radiological anterior posterior laxity and IKDC scores. However, significant between-group differences were found between the preoperative and postoperative evaluations.

Meniscal repair using the FasT-Fix device in patients with chronic meniscal lesions.

The aim of this prospective study was to evaluate meniscal suturing using the FasT-Fix device for chronic meniscal tears. This procedure was carried out on 25 patients between 2006 and 2007. Nineteen patients were male and the median age was 31 (14-47) years. The median waiting time to surgery was 27 (6-80) months and the median follow-up was 20 (14-29) months. Eleven patients (44%) required reconstruction of an associated anterior cruciate ligament (ACL) injury. 20 patients (80%) showed medial meniscus tears. All tears were located in the red zone or red-white zone. According to Barett's criteria, meniscal tear healing was achieved in 21 patients (84%). Lysholm and Tegner scale scores improved from 60 (47-77) preoperatively to 95 (58-100) postoperatively and from 3 (2-6) preoperatively to 6 (3-9) postoperatively, respectively. There were no neurovascular complications. Revision surgery was necessary in one patient, in whom a partial meniscectomy was performed. The results obtained suggest that chronic meniscal tears in the zones described can be healed.

GM-CSF Expression and Macrophage Polarization in Joints of Undifferentiated Arthritis Patients Evolving to Rheumatoid Arthritis or Psoriatic Arthritis.

Background and Aims: GM-CSF-dependent macrophage polarization has been demonstrated in rheumatoid arthritis (RA). Our aim was to seek diagnostic/prognostic biomarkers for undifferentiated arthritis (UA) by analyzing GM-CSF expression and source, macrophage polarization and density in joints of patients with UA evolving to RA or PsA compared with established RA or PsA, respectively. Methods: Synovial tissue (ST) from patients with UA evolving to RA (UA>RA, n=8), PsA (UA>PsA, n=9), persistent UA (UA, n=16), established RA (n=12) and PsA (n=10), and healthy controls (n=6), were analyzed. Cell source and quantitative expression of GM-CSF and proteins associated with pro-inflammatory (GM-CSF-driven) and anti-inflammatory (M-CSF-driven) macrophage polarization (activin A, TNFα, MMP12, and CD209, respectively) were assessed in ST CD163+ macrophages by multicolor immunofluorescence. GM-CSF and activin A levels were also quantified in paired synovial fluid samples. CD163+ macrophage density was determined in all groups by immunofluorescence. Results: Synovial stromal cells (FAP+ CD90+ fibroblast, CD90+ endothelial cells) and CD163+ sublining macrophages were the sources of GM-CSF. ST CD163+ macrophages from all groups expressed pro-inflammatory polarization markers (activin A, TNFα, and MMP12). Expression of the M-CSF-dependent anti-inflammatory marker CD209 identified two macrophage subsets (CD163+ CD209high and CD163+ CD209low/-). CD209+ macrophages were more abundant in ST from healthy controls and PsA patients, although both macrophage subtypes showed similar levels of pro-inflammatory markers in all groups. In paired synovial fluid samples, activin A was detected in all patients, with higher levels in UA>RA and RA, while GM-CSF was infrequently detected. ST CD163+ macrophage density was comparable between UA>RA and UA>PsA patients, but significantly higher than in persistent UA. Conclusions: GM-CSF is highly expressed by sublining CD90+ FAP+ synovial fibroblasts, CD90+ activated endothelium and CD163+ macrophages in different types of arthritis. The polarization state of ST macrophages was similar in all UA and established arthritis groups, with a predominance of pro-inflammatory GM-CSF-associated markers. CD163+ macrophage density was significantly higher in the UA phases of RA and PsA compared with persistent UA. Taken together, our findings support the idea that GM-CSF is a strong driver of macrophage polarization and a potential therapeutic target not only in RA but also in PsA and all types of UA.

Role of musculoskeletal disorders as concurrent chronic conditions: are they underestimated in the discharge?

BACKGROUND: Differences in recording concurrent chronic conditions (CCs) could change the weight of the influence of the different CCs on health status. OBJECTIVES: To determine the role of musculoskeletal disorders as concurrent CCs. METHODS: Cross-sectional study. Discharged patients with CCs were selected by random stratification. Sociodemographic and clinical variables, health status (SF-36), type and number of self-reported and hospital discharge summary CCs were recorded. Relationships were analyzed using linear regression models. RESULTS: In the 227 patients included, mean self-reported CCs were 6.22 (SD 3.37) and mean hospital discharge CCs were 3.1 (SD 1.95). The most-frequent self-reported CCs were hypertension 48.4%, back pain 40.4%, neck pain 39.6%, and musculoskeletal disorders 38.4%. The most frequent discharge CCs were arterial hypertensive disease 38.3%, all cancers 22.0%, ischemic heart diseases, and angina 15.9%. Musculoskeletal disorders had the greatest negative influence on SF-36 dimensions (p < 0.05). CONCLUSIONS: Musculoskeletal disorders were underestimated in the discharge summary in comparison with those reported by patients.

Total knee arthroplasty: better short-term results after subvastus approach: a randomized, controlled study.

The purpose of this study was to evaluate the short-term results after performing a total knee arthroplasty (TKA) using two surgical approaches: the subvastus approach (SV) and the conventional parapatellar approach. It was hypothesized that the SV approach would achieve the best short-term benefits. This is a randomized prospective and double-blind study that includes 104 patients. Evaluations were carried out preoperatively, when discharged (5 days) at one, three, and 12 postoperative months. The SV group showed significantly better range of movement and quadriceps extensor force when discharged. Statistically significant differences were found that showed a distinct improvement in favour of the SV group at one month in terms of extensor force and according to the Barthel Index. No significant difference was found between the two groups at the 12 month evaluation. It was concluded that the SV approach offers superior short-term clinical and functional results and it was shown that this approach also offers a significant advantage to the patient in the immediate postoperative period, although these differences tend to disappear over time following TKA. We strongly recommend the SV approach in the majority of TKA.

Biomechanical comparison of anterolateral ligament anatomical reconstruction with a semi-anatomical lateral extra-articular tenodesis. A cadaveric study.

BACKGROUND: To compare the biomechanical behavior of an anterolateral ligament (ALL) anatomical reconstruction and a semianatomical lateral extra-articular tenodesis (LET) in the context of an anterior cruciate ligament (ACL) reconstruction combined with an anterolateral lesion. METHODS: Twelve cadaveric knees were studied using a testing machine to assess the internal tibial rotation and anterior tibial translation across six surgical states: intact knee, ACL lesion, ACL + ALL lesion, ACL isolated reconstruction, ACL + ALL anatomical reconstruction and ACL + LET procedure. ALL and LET grafts were fixed at full knee extension and neutral rotation. RESULTS: Presented with combined ACL and ALL lesions, isolated ACL reconstruction failed to restore the internal tibial rotation to intact-knee values (P > 0.05 for all angles). The addition of both an ALL reconstruction and LET procedure significantly reduced the internal rotation, restoring the rotation laxity to intact-knee values at 0° and 30° of flexion (P < 0.05) and with a certain level of overconstraint at 60° and 90° (mean 3°â€¯±â€¯2SD). A higher tendency to overconstraint was observed with the LET, but there was no significant difference when comparing the ALL reconstruction with the LET (P > 0.05 for all angles). CONCLUSIONS: Residual rotational laxity was found after isolated ACL reconstruction in the presence of an anterolateral lesion. The combination of ACL reconstruction with anatomical ALL reconstruction or the LET procedure resulted in restoration to intact-knee values but with a certain degree of overconstraint in higher flexion angles. Both techniques showed optimal biomechanical results with no data supporting the advantage of one over the other.

Prevalence of knee osteoarthritis and analysis of pain, rigidity, and functional incapacity.

Knee osteoarthritis is one of the most prevalent health problems in our society. It accounts for 10% of all primary care visits in general medicine and 30% of outpatient appointments. The objectives of this cross-sectional descriptive study of 100 patients suffering from gonarthritis were to assess pain, functional capacity, and joint damage in patients diagnosed with knee osteoarthritis, as well as the possible repercussions for subsequent surgical treatment. Sociodemographic, clinical, and radiological data were collected, and pain and functional capacity were evaluated by using the Western Ontario and McMaster Universities Osteoarthritis Index. The majority (71) of patients were women, mean age 71 years (SD=7.84), of low educational (66%) and financial (89%) status, with mean disease duration of 11.8 years. Of the total, 87% presented with comorbidity. Radiographs revealed a varus malalignment in 31% of patients and a valgus malalignment in 17%, with bone collapse in 39% of these. The factors that most affect surgery and subsequent rehabilitation are closely linked to social status, the general state of the patient, and the radiological severity of gonarthritis. Most of the patients were obese and suffered from comorbid conditions, and some presented with psychopathology. These factors may influence surgery, and thus improvements in primary care should be made as a way of offering a simpler and more effective treatment for gonarthritis.

Severe and morbid obesity and transfusional risk in total knee arthroplasty: An observational study.

BACKGROUND: Severe and morbid obesity (Class II -III) represents a challenge for successful knee surgery. There isn't consensus on what influence body mass index has on blood loss and on red blood cell (RBC) transfusion during total knee arthroplasty (TKA). The objective was to determine blood loss and transfusion needs in severe and morbid obese patients undertaking TKA. METHODS: We recorded retrospectively all patients undergoing TKA. Obesity was assessed according to WHO guidelines. Perioperative haemoglobin and treatments for its optimisation were recorded. Blood losses were estimated from specific formulae for lost red-cell mass and percentage of lost blood volume. RESULTS: 922 patients were included: 35.90% were obese Class I and 18.76% obese Class II - III. Estimated blood volume was 4390  ±â€¯â€¯470 ml, 4736  ±â€¯â€¯423 ml and 5030 ±â€¯464 ml among non-obese, obese Class I and obese Class II-III, respectively (P < 0.001). The global estimated blood volume (EBV) lost was 1502  ±â€¯â€¯680 ml without differences between the three groups. However, the percentage of lost blood volume was lower in obese Class II -III (29.65%) than in non-obese (33.55%) and obese Class I (30.97%) (P < 0.005). Transfusion rates were 12.7%, 12.1% and 6.4% for non-obese, obese Class I and Class II -III, respectively (P = 0.062). A negative transfusion risk was predicted for Class II -III patients. CONCLUSIONS: Severely and morbidly obese patients did not show greater blood loss nor higher RBC transfusion needs after primary TKA than non-obese and obese Class I patients. This could be because obese Class II -III patients had higher EBV but similar RBC losses.